Tratamiento antifúngico individualizado en el paciente crítico con infección fúngica invasora

Invasive candidiasis (IC) is the most common invasive fungal infection (IFI) affecting critically ill patients, followed by invasive pulmonary aspergillosis (IPA). International guidelines provide different recommendations for a first-line antifungal therapy and, in most of them, echinocandins are considered the first-line treatment for IC, and triazoles are so for the treatment of IPA. However, liposomal amphotericin B (L-AmB) is still considered a second-line therapy for both clinical entities. Although in the last decade the management of IFI has improved, several controversies persist. The antifungal drugs currently available may have a suboptimal activity, or be wrongly used in certain IFI involving critically ill patients. The aim of this review is to analyze when to provide individualized antifungal therapy to critically ill patients suffering from IFI, emphasizing the role of L-AmB. Drug-drug interactions, the clinical status, infectious foci (peritoneal candidiasis is discussed), the fungal species involved, and the need of monitoring the concentration of the antifungal drug in the patient are considered.     

Evolución de la infección fúngica invasora en los últimos 30 años

Clinical mycology is in continuous development. The appearance of new clinical guidelines has made it possible to improve the approach to opportunistic fungal infections, especially in immunosuppressed patients (oncohematological and/or transplant recipients). At the same time, the development of new diagnostic tools and new antifungals with a greater spectrum of action and fewer side effects have led to faster diagnoses and treatments that are more effective. Along with these advances, there has been a change in the epidemiology of invasive fungal infection (IFI), with the appearance of new patients (e.g., COPD, liver cirrhosis, post-influenza) and new microorganisms (Candida auris, Lomentospora prolificans, mucorales), and resistant fungi (isolates of Aspergillus resistant to azoles) which the clinician must take into account when choosing the treatment of a patient with an IFI. In this paper we will briefly review the advances in recent decades and the emerging problems.     

Particularidades clínicas del paciente crítico con infección fúngica invasora

BackgroundInvasive fungal infection (IFI) is an entity that encompasses different types of infections caused by different types of those fungi pathogenic for humans. In the setting of critically ill patients with multiple and oftenconcurrent risk factors and comorbidities the most common are those caused by the Candida and Aspergillus species. Among the characteristics of IFI in critically ill patients, three aspects can be highlighted: those related to the host (e.g.: risk factors, clinical severity), those related with the pathogen (sensitivity, virulence), or those concerning antifungal treatment (spectrum, features PK / PD, safety, interactions). The fungus that most often causes an IFI in critically ill patients is Candida; the most common type infections are candidemia, Candida peritonitis and catheter-related infections. In recent years new antifungal treatments have expanded the therapeutic options, with echinocandins as a clear choice, often the first in the latest guidelines in critically ill patients with IFI.Case reportWe report the case of a critically ill patient having the most common risk factors, multiple organ dysfunction and development of an IFI. The complexity of establishing an antifungal treatment from the moment of its inception, its setting, and the considerations of the different therapeutic possibilities according to organ dysfunction of the patient are discussed. The antifungal treatment options mentioned in the current guidelines and recommendations are also evaluated.ConclusionsThe most common fungal infection in critically ill patients is invasive candidiasis, with candidemia or candida peritonitis being the most frequent clinical presentations. Candins have brought new possibilities for treating these complex patients due to their good safety profile and clinical efficacy.     

Micafungina en el tratamiento de la infección fúngica en modelos animales

BackgroundMicafungin is an echinocandin antifungal drug recently approved for the treatment of candidiasis. The possibility of its clinical use against other invasive mycoses, has aroused the interest of numerous investigators in evaluating its efficacy in different animal models.ObjectivesTo critically review the current data on the use of micafungin in the treatment of invasive mycoses in animal models.MethodsWe searched the PubMed/Medline data base (National Library of Medicine) from 2005 to 2008, both inclusive, on the use of micafungin in the experimental treatment of the fungal infection.Results and conclusionsSeven, of a total of 18 articles reviewed, were done in animal models of candidiasis and six in animal models of pulmonary or SNC aspergillosis. Similarly to the other echinocandins, caspofungin and anidulafungin, micafungin seems to exert a fungicidal activity against Candida albicans and Candida glabrata and a fungistatic activity against Aspergillus fumigatus. The paradoxical effect observed in lung tissue the experimental caspofungin treatment of aspergillosis has not been seen in the case of micafungin. The available data demonstrate a higher efficacy of micafungin versus fluconazole in the experimental treatment of C. albicans infections caused by strains susceptible in vitro to both drugs. To improve the efficacy of micafungin in the treatment of C. glabrata and A. fumigatus infections, several authors have tested different combined therapies, the combination of micafungin with amphotericin B being that showed the best results.     

Primer caso de infección fúngica invasora por Candida fabianii en un paciente pediátrico no neonatal

BackgroundInvasive fungal diseases have increased in recent years. Candida species are the most common aetiology. Candida albicans, Candida parapsilosis, Candida tropicalis, Candida glabrata and Candida krusei are the cause of most of them. The aim of this work is to describe the first isolation of Candida fabianii in the blood of a non-neonatal paediatric patient.Case reportA 2 year-old male with short bowel syndrome, severe malnutrition, and hypophosphataemic rickets deficiency was admitted to paediatric intensive care due to a respiratory tract infection and suspicion of an intestinal pseudo-obstruction. He received several cycles of broad-spectrum antibiotics for several infections due to Pseudomonas aeruginosa and Escherichia coli. After the surgical correction of the intestinal disorder he suffered a new episode of sepsis where yeasts were isolated by culture. The species identification was performed by means of mass spectrometry (MALDI-TOF system, Bruker Daltonic). The identity of the isolate was C. fabianii (anamorph)/Pichia fabianii (teleomorph) with a score of 2.149. Antifungal treatment with caspofungin was prescribed, with good progress of the patient.ConclusionsMolecular techniques are important for the identification of these species, although mass spectrometry offered a reliable and rapid diagnosis. Treatment with caspofungin was effective.     

Genotipificación de aislamientos clínicos de Aspergillus flavus y su relación con aislamientos ambientales de un centro oncohematológico

BackgroundDuring 4 months, and while conducting an environmental sampling of air, 2 cases of aspergillosis by Aspergillus flavus (A. flavus) were diagnosed at an oncohematological center in Buenos Aires, Argentina.AimsThe aim of this study was to know the variability and the genetic relationship between the clinical and environmental isolates, obtained in the oncohematological center.MethodsTwo genotyping techniques of different discriminatory power (RAPD and AFLP) were used. A genetic similarity matrix was calculated using Jaccard method and was the basis for the construction of a dendrogram by UPGMA. The level of genetic variability was assessed by measuring the percentage of polymorphic loci, number of effective allele, expected heterocygozity and association index test (I_A).ResultsThe dendrogram reveals that the A. flavus isolates recovered from the patients were not genetically related to those gotten from the rooms occupied by the patients. The environmental isolates had higher values of genetic diversity than the clinical isolates. The I_A estimated for all the isolates suggest that recombination events occurred.ConclusionsPatients 1 and 2 were not infected with isolates from the nosocomial environment. Clinical and environmental isolates of A. flavus showed high genetic variability among them.     

Infección múltiple fúngica en un paciente diabético

BackgroundMixed fungal infections although undervalued, are more common than mentioned in the scientific literature. These infections have a poor prognosis for the patient.ObjectivesWe present an unusual case of a 61-year-old diabetic male who had a rhino-orbito-sinusal zygomycosis in 2001. After surgical debridement of the infected parts, along with antifungal therapy with liposomal amphotericin B, the patient started improving. Several years later the patient was hospitalized due to a similar problem and was diagnosed of rhino-orbito-cerebral zygomycosis.MethodsIn both episodes, a histopathological examination and cultures were performed on the sinus lesions. Tissue sections were stained with haematoxylin and eosin, Giemsa, periodic acid-Schiff (PAS) and Grocott's methenamine silver, and cultures specific for fungi were performed.ResultsThe histopathology studies revealed the presence of bacteria, actinomyces and a mixed infection by at least four different fungi, all of them well differentiated by their morphology. Despite the rapid diagnosis the patient died due to spreading to the central nervous system.ConclusionsMixed infections by fungi are rare, but due to the high incidence of immunodeficiencies they could occur more often than reported. We would like to alert on the possibility of acquired mixed infection by fungi which have shown to be high aggressive and have a worse prognostic in patients with underlying diseases.     

Tratamiento y evolución del síndrome de tormenta de citoquinas asociados a infección por SARS-CoV-2 en pacientes octogenarios

IntroductionCytokine storm syndrome (CTS) is a serious complication of patients with SARS-CoV-2 infection. Treatment and evolution in octogenarians are not well defined. Our objective is to describe its clinical characteristics, the treatments and its clinical evolution.Patients and methodRetrospective observational study of consecutive patients admitted in the period between March 23 and April 12, 2020 with confirmed SARS-CoV-2 infection, with pneumonia by radiological study or chest tomography, whith STC criteria and who received treatment. We classified patients as those who received only glucocorticoid (GC) pulses, or GC and tocilizumab pulses. We determined serum levels of ferritin, CRP and D-dimers. The final variable was survival.Results21 patients, (80-88 years). The mean ferritin was 1056 microg/L (317-3,553), CRP 115.8 mg/dL (22-306) and D-dimers 2.9 m/L (0.45-17.5). All patients received GC pulses and in 2 cases simultaneously tocilizumab. The mean follow-up time was 13.7 days (8-21). The overall mortality was 38.1% (8/21 patients). The 2 patients who received tocilizumab died. The deceased had significantly higher levels of ferritin (1,254 vs. 925 microg/L; P = .045) and CRP (197.6 vs. 76 mg / dL; P = .007). At the end of the follow-up, a decrease in the biochemical parameters was observed with ferritin of 727 microg/L, CRP of 27 mg/dl and D-dimers of 1.18 mg/L. In 13/21 patients (61.9%), the CTS was controlled without the need to add other treatments.ConclusionsSTC mortality from SARS-CoV-2 is high despite treatment. A greater inflammatory response was associated with a higher mortality. Although it seems that the early use of GC pulses could control it, and the use of other treatments such as tocilizumab shouldo be, with the study design and its limitations, this conclusion cannot be stablished.     

Mortalidad en pacientes con demencia que cursaron internación en unidades de cuidados críticos

ObjectiveTo determine the mortality and comorbidities associated of patients with dementia admitted to the Intensive Care Unit (ICU) on the hospitalization and at one year of follow-up.Materials and methodsA retrospective observational cohort study was carried out between 2012 and 2017 at the Hospital Italiano de San Justo, of patients who were admitted to the ICU, these were observed up to hospitalary death, out hospital death one year of hospitalization, the disenrollment from the institution's health plan or the end of the follow-up.ResultsA total of 163 patients were included for analysis. We recorded those 79 patients (48.47%) died one year after the hospitalization, of them 25 (15.34%) in ICU and 8 (4.91%) in general room. The most frequent causes of death were respiratory. The factors most associated with mortality were: orotracheal intubation (HR = 2.01; 95% CI: 1.11-3.65; P = .02), history of leukemia (HR = 8.55; 95% CI: 1.82-40.05; P ≤ .05), elevated Charlson (HR = 1.16, 95% CI: 1.04-1.41; P = .05), and elevated APACHE II at admission (HR = 1.07; 95% CI: 1.03-1.11; P ≤ .05).ConclusionsThe present study expresses the prognosis of patients with a diagnosis of dementia admitted to the ICU and that depends not only on their baseline neurological status but also on the severity at admission and comorbidities.     

Determinación de la certeza diagnóstica de la gammagrafía tiroidea con tecnecio 99 sestamibi en pacientes con nódulo tiroideo y resultado histopatológico definitivo

Background99mTc sestamibi scanning and aspiration biopsy can predict the histopathological result of a thyroid nodule fairly accurately.ObjectiveTo determine the accuracy of 99mTc sestamibi scanning in detecting malignancy in patients with thyroid nodule confirmed by definitive histopathological report after thyroidectomy.Material and methodsA total of 69 patients with a solitary thyroid nodule were studied. In all patients, fine needle aspiration, total thyroidectomy for suspected thyroid cancer, and histological analysis of the surgical specimen were performed. There were 54 patients with a positive 99mTc sestamibi scan; of these, malignancy was confirmed by histological analysis in 25 and excluded in 29. There were 15 patients with a negative 99mTc sestamibi scan; of these, three had a final diagnosis of cancer and 12 were confirmed as cancer-free.ResultsThe diagnostic accuracy of 99mTc sestamibi scanning in detecting malignancy in thyroid nodules was determined through a statistical analysis. 99mTc sestamibi scan for thyroid cancer had a sensitivity of 89.28% and a specificity of 29.25%. The positive predictive value was 46.29% and the negative predictive value was 80%.ConclusionsWe believe that 99mTc sestamibi scan should be routinely used in all patients with a thyroid nodule and an indeterminate result on fine needle aspiration. This procedure is most useful in excluding malignancy in patients with a negative 99mTc sestamibi scan.     

Revision crítica de la investigación y de la literatura micológica en el uruguay en el período 1946–1956

Sans résumé     

Recuperación funcional al alta y a tres meses tras una intervención multicomponente de ejercicio físico en ancianos hospitalizados en una unidad de agudos de geriatría

IntroductionHospitalization in the elderly, even in short stays, is associated with functional impairment. Once the acute illness is reversed, the evolution of this hospital-generated impairment can be variable, and a year after hospitalization more than half of the elderly patients remain impaired. This impairment is associated with a higher risk of institutionalization, of mortality at discharge and of 30-day mortality. Previous studies have shown how interdisciplinary physical exercise programs can improve functionality at discharge and decrease mortality rate, hospital stay and institutionalization.Study design and objectivesIn the Acute Geriatric Unit of the Gregorio Marañon University hospital a randomized controlled trial was carried out to assess the effectiveness of an exercise and health education program to prevent functional decline during hospitalization and at three months after discharge in elderly subjects aged 74 years or older. Patients were excluded if at least one of the following exclusion criteria was met: baseline Barthel Index (15-days prior hospitalization) below 20, severe cognitive impairment or inability to walk. The intervention consisted on a physical exercise program (that included squats, balance, gait stimulation, elastic bands, and inspiratory muscle training) and health education program. The control group received usual care.     

Evaluación de las complicaciones clínicas de los pacientes con fractura de cadera y sus factores asociados en una Unidad de Agudos de Ortogeriatría

Introduction

The incidence of clinical complications in hip fracture (HF) patients is high and variable due to their heterogeneous nature. The aim of the study was to assess the clinical complications and their associated factors in HF patients admitted to the Orthopaedic Geriatric Unit of a 283 bed University Hospital. An average of 200 HF patients is attended yearly.

Características y resultados tras un año en pacientes ancianos ingresados con insuficiencia cardiaca y fracción de eyección reducida,intermedia o conservada

IntroductionThe latest European Society of Cardiology Heart Failure (HF) guidelines define three types of HF according to the ejection fraction (EF): HF with reduced EF (HFrEF) when EF < 40%, HF with mid-range EF (HFmrEF), when EF 40-49%, and HF with preserved EF (HFpEF) when EF ≥ 50%. The objective of this study was to analyse the characteristics and results of elderly patients hospitalised with HF according to the new classification using EF.MethodsA prospective study was carried out with 531 HF patients aged ≥ 75 years classified according to EF, and admitted in the geriatric wards of 6 hospitals in Spain. An analysis was performed on the demographic and clinical characteristics, as well as well as the morbidity and mortality at one year of follow-up.ResultsAs regards EF, 17.1% had HFrEF, 10% had HFmrEF, and 72.9% had HFpEF. Patients with HFmrEF were more similar to those with HFrEF in terms of a younger age, predominance of men, and previous admission due to HF. This was also the case with the use of drugs for neurohormonal blockade. Patients with HFrEF (compared to those with HFmrEF and HFpEF), had higher mortality (35.2%, 24.5%, and 25.6%, respectively), more readmissions for HF (17.6%, 15.1%, and 14.5%, respectively), and more events (61.5%, 45.3%, and 52.5%, respectively), although there were no significant differences. There were also no differences observed in the survival analysis between the EF groups and the time-dependent outcome variables.ConclusionsIn elderly patients hospitalised with HF, those classified as HFmrEF did not show any clear differences with respect to those with HFrEF or HFpEF. There were no differences in terms of morbidity and mortality.